We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. lf you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.

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Patient Registration

Preferred Name

Patient Name

Date of Birth

Sex

Address

Home Phone

Work Phone

Cell Phone

Social Security Number

Driver's License #

Email

How did you hear about our office?

IN CASE OF EMERGENCY, name and phone of nearest relative not living with you:

Financially Responsible Person

x

Check if same as above

Name

Address

Relationship to Patient

Date of Birth

Home Phone

Work Phone

Cell Phone

Social Security Number

Drivers License #

Employment of Responsible Person

Name of Employer

Present Position

Address

SPOUSE

Name

Date of Birth

Social Security Number

Name of Employer

Work Phone

Address

Please complete the following if you have dental insurance.

Name of Primary Dental Insurance

Address

Group #

ID #

Employee/Subscriber Name

Employer (Company) Name

Address

Phone

Name of Secondary Dental Insurance

Address

Group #

ID #

Employee/Subscriber Name

Employer (Company) Name

Address

Phone

Page Break

Dental History

What dental care would you like us to provide?

Do you have PAIN, SWELLING, or SORE SPOTS at this time?x

YesNo

Have you had any COMPLICATIONS with dental treatment?x

YesNo

Do your GUMS BLEED?x

YesNo

Have you had GUM TREATMENTS?x

YesNo

If you SNORE, would you like an oral device to help you?x

YesNo

Do you have BAD BREATH?x

YesNo

Is this your first visit to ANY dentist?x

YesNo

Have you been treated for TMJ (Temporomandibular joint) problems?x

YesNo

Do you have REMOVABLE dentures or partials?x

YesNo

If yes, are they UPPER or LOWER dentures or partials, or both?x

UpperLowerBoth

Do you have a FEAR of dentistry?x

YesNo

If yes, why?

Do you like your SMILE?x

YesNo

Is your WATER FLUORIDATED?x

YesNo

Have you had a complete set of X-RAYS taken in the past 3 years?x

YesNo

If yes, where?

Have you visited our website at www.drmorin.com?x

YesNo

When was your last dental visit?

In order for us to provide you with the best quality of care, we like to get to know you better. As a provider, all of the following are important to us, however, we would like to know which is most important to you. Please select all that apply.

FUNCTION - Are you having any issues chewing or eating?‎COMFORT - Are you having any pain or discomfort?‎COSMETIC - Are you happy with your smile? Interested in whitening?‎LONGEVITY - Are you interested in the longest lasting treatments?‎

When considering having treatment done, which of the following would be a concern to you? Please select all that apply.

FEAR - Do you have a fear of going to the dentist?‎TIME - Is time an issue for you? Do you have a very busy schedule?‎BUDGET - Are finances a concern for you?‎NO SENSE OF URGENCY - Do you only come to the dentist when it hurts?‎NO TRUST - Have you had a bad experience or been told you need treatment you felt you did not need?‎

What would you say would be the most important quality for you in a relationship with your dentist?

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?x

YesNo

If yes

Have you ever been hospitalized or had a major operation?x

YesNo

If yes

Have you ever had a serious head or neck injury?x

YesNo

If yes

Are you taking any medications, pills, or drugs?x

YesNo

If yes

Do you take, or have you taken, Phen-Fen or Redux?x

YesNo

If yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?x

YesNo

If yes

Are you on a special diet?x

YesNo

Do you use tobacco?x

YesNo

Women: Are you...

Pregnant/Trying to become pregnant‎Nursing‎Taking oral contraceptives‎

You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

Do not consent to treatment unless and until you discuss potential benefits, risks and' complications with your dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.

Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:

Pain, swelling and discomfort after treatment;

Infection in need of medication, follow-up procedures or other treatment;

Temporary, or, on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums and tongue along with possible loss of taste;

Damage to adjacent teeth, restorations or gums;

Possible deterioration of your condition which may result in tooth loss;

The need for replacement of restorations, implants or other appliances in the future;

An altered bite in need of adjustment; Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist;

A root tip, bone fragment or a piece of a dental instrument may be left in your body, and may have to be removed at a later time if symptoms develop;

Jaw Fracture;

If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment;

Allergic reaction to anesthetic or medication;

Need for follow-up care and treatment, including surgery.

It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise your dentist immediately so he/she can consult with your physician if necessary.

The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.

If you are a woman on oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking, antibiotics.

This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood and accepted each paragraph stated above. Please discuss the potential benefits, risks and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.

I hereby authorize HI-TECH Family Dentistry to administer dental treatment and local anesthetic and /or nitrous oxide (laughing gas) and to perform procedures deemed necessary in the diagnosis and dental treatment of the above named patient. I further authorize HI-TECH Family Dentistry or anyone acting on his behalf to release information acquired in the course of the patient examination or treatment. I also consent to and authorize HI-TECH Family Dentistry to process insurance claims, communicate with insurers or other third parties, including my employer, who may have information pertaining to the payment of services. I hereby assign to HI-TECH Family Dentistry benefits which are due or are to become due as a result of dental services rendered to the above mentioned patient. I hereby authorize that payments be made directly to HI-TECH Family Dentistry. Dr. Morin often takes photos to better explain certain aspects of your existing dental health or planned treatment to you. We request your permission to show these photographs to better explain treatment options to other patients (as you will be shown photos for the same reason). And since he has a reputation as an expert on Cosmetic Dentistry, he also makes presentations to other dentists and professionals where the photos are invaluable in explaining the latest techniques and the results that can be achieved when done precisely. We also request your permission to post photographs of you and your smile on our website. I agree to pay for all professional fees and treatment at the time of service, or my portion not covered by dental insurance, for myself or the above named patient, unless other financial arrangements are approved. I also agree to pay for all costs of collection, including attorney fees, and court costs, should additional means of collection be required.

x

I have read the above Informed Consent Form and agree to its terms and conditions.

I acknowledge that I have received, and/or reviewed the notice of the privacy practices of this office. I am aware that I may receive a paper copy of this notice if I request it. In addition, I acknowledge that this notice of the practice's privacy practices is posted in the office where I can review it if desired.